2008 HEALTH NET MEDICARE PART D SAMPLE ID CARDS SAMPLE - PDP ID CARD Health Net Orange Member questions call 1-800-806-8811 (TTY/TDD: 1-800-929-9955) A Medicare Prescription Drug Plan ID: R00000000-00 Name: FIRST MI LAST Effective: 2008 HN Group ID: 123456A Rx Claims Processor: Caremark RxBIN: 004336 RxPCN: ADV RxGrp: RX6270 Issuer: (80840) Material ID: S5678_2007_85 CMS Approved 09/07 CMS_S5678 XXX For Provider Inquiries, Call 1-888-949-4200 For Pharmacist Inquiries, Call 1-888-865-6567 Submit Part D Prescription Drug Claims to: Health Net Attn: Claims 10540 White Rock Rd., Ste. 280 Rancho Cordova, CA 95670 SAMPLE - PFFS ID CARD Member questions call 1-800-977-8221 (TTY/TDD: 1-800-929-9955) Health Net Pearl A Medicare Advantage Private Fee for Service Plan Name: FIRST MI LAST ID: R00000000-00 Group ID: 123456A Specialist Copay: $### Effective: 01-01-2008 Issuer: (80840) Office Visit Copay: $### Emergency Room Copay: $### Part D Claims Processor: Caremark RxBIN: 004336 RxPCN: ADV RxGrp: RX6270 Providers: Do not bill Original Medicare. Health Net Pearl is a Medicare Advantage Private Fee-For-Service Plan. For terms and conditions of payment, go to www.healthnet.com or call 1-800-977-8221. For Pharmacist Inquiries, Call 1-888-865-6567 Submit Medical and Part B Drug Claims to: P.O Box 2226 Augusta, GA 30903-2226 Submit Part D Drug Claims to: Health Net - Claims 10540 White Rock Rd., Ste 280 Rancho Cordova, CA 95670 Decision PowerSM –To access a Health Coach (24 hours a day, 7 days a week) call: 1-800-893-5597 (TTY/TDD: 1-800-276-3821) Material ID M0004-PFFS-07-081 CMS Approved: 09/07 CMS_H5996-H5721 XXX Electronic Claims Submission to: Professional Payer ID: SX185 Institutional Payer ID: 12X48 SAMPLE - HNAZ MAPD ID CARD This card is for identification purposes only and does not guarantee eligibility Card Issuer ID: 80840 Contract: H0351-014 Subscriber: SAMPLE MEMBER ID#: HN0000000 01 Plan: RUBY OPTION 1 PCP:$0 Specialist:$35 Group#: AZ0007 Urgent Care:$35 ER:$50 RxClaims Processor: Caremark RxBIN: 004336 RxPCN: ADV RxGROUP: RX6270 Important Member Phone Numbers: Customer Contact Ctr: 1-800-977-7522 TTY: 1-800-977-6757 Hours of operation Monday-Friday, 8am - 8pm Decision Power: 1-800-893-5597 TTY: 1-800-276-3821 Hours of operation 24 hours/day, 7 days/ week Hospitals and Physicians: 1-800 289-2818 Prior Authorization: 1-800 977-7518 Behavioral Health: 1-800-977-0281 TTY: 1-866-726-1785 MEDICAL CLAIMS: To submit claims, complete a current original CMS-1500 or UB92. Include the Health Net ID # and the member’s two-digit billing code which appears on the front of this card. Mail claims to Health Net, P.O. Box 14225, Lexington, KY 40512-4225. Electronic claims: Contact our EDI Dept. at 1-866-334-4638 or 1-866-EDI-HNET. Pharmacies Call: 1-800-410-6565 Caremark:1-888-865-6567 PHARMACY CLAIMS: Mail claims to Health Net, Attn: Pharmacy, 950 N. Finance Center Drive, Tucson, AZ 85710 page 1 SAMPLE - HNCA MAPD ID CARD FRONT OF CARD You have selected the following medical group for your care. All medical services, with the exception of emergency, urgently needed services, or out of the area renal dialysis for ESRD members, as defined in your Evidence of Coverage, must be provided or arranged by: Group/Physician Name: HILL PHYSICIANS - ABSMC JANE Q. PROVIDER 1234 Main Street SACRAMENTO CA 00000 PPG Eff. Date: 01-01-08 PPG #: 0000 PCP Copay: $10 copayment Group Phone: 1-925-820-8300 (TTY/TDD: 1-877-735-2929) Physician Phone: 1-800-555-1234 (TTY/TDD: 1-877-735-2929) Health Net Medicare Advantage HMO Subscriber Name: JOHN DOE Subscriber #: R0000000 RxProcessor: Caremark RxBIN #: 004336 RxPCN #: ADV RxGroup: RX6270 Group # 00000F Issuer: (80840) CMS Contract H0562 068 Plan: 2T6 WITH PHARMACY RUBY BACK OF CARD For questions or concerns, call the Member Services Department at 1-800-275-4737 (TTY/TDD: 1-800-929-9955) 8:00 a.m to 8:00 p.m., 7 days a week. For Provider inquiries, call 1-800-929-9224. Medical Claims: Health Net Medicare Advantage Claims P.O. Box 14702 Lexington, KY 40512 Pharmacists call 1-888-865-6567. For mental health benefits, call MHN at 1-800-646-5610 (TTY/TDD: 1-800-327-0801) Pharmacy Claims: Health Net of California Attn: Pharmacy P.O. Box 9103 Van Nuys, CA 91409-9103 To contact a Decision Power Health Coach, call 1-800-893-5597 (TTY/TDD: 1-800-276-3821) 24 hours a day, 7 days a week If an emergency arises: Call 911 or go to the nearest hospital or emergency care facility. If you are unsure of the seriousness of your condition, you may call your physician for assistance. Material ID# H0562-07-0145 CMS Approval (10/07) SAMPLE - HNNE MAPD ID CARD This card is for identification purposes only and does not guarantee eligibility Card Issuer ID: 80840 Contract: CT0755-022 Subscriber: SAMPLE MEMBER ID#: HN0000000 01 Plan: Group#: 006453 PCP:$15 Specialist:$30 Urgent Care:$30 ER:$50 RxClaims Processor: Caremark RxBIN: 004336 RxPCN: ADV RxGroup: RX6270 Important Member Phone Numbers: Customer Contact Ctr: 1-800-547-8734 TTY: 1-888-747-2424 Hours of operation Monday-Friday, 8am - 8pm EST Hospitals and Physicians: 1-800-438-7886 Healthy Lifestyles: 1-888-747-9444 TTY: 1-888-747-2424 Behavioral Health: 1-800-627-7715 TTY: 1-800-855-2881 MEDICAL CLAIMS: To submit claims, complete a current original CMS-1500 or UB92. Include the Health Net ID # and the member’s two-digit billing code which appears on the front of this card. Mail claims to Health Net, P.O. Box 14700, Lexington, KY 40512-4225. Electronic -Payer ID 06108, EDI Dept. 1-866-334-4638. Pharmacy Help Desk: 1-888-865-6567 PHARMACY CLAIMS: Mail claims to Health Net of the Northeast, Attn: Pharmacy Mgmt.- Medicare Part D, P.O. Box 904, Shelton, CT 06484-9831 page 2 SAMPLE - HNOR MAPD ID CARD FRONT OF CARD Health Net Medicare Advantage PPO Health Net Medicare Advantage PPO Office Visit Emergency Room Urgent Care Facility Hospital In Network $15 20% $25 20% per day (Days 1-10) Website: www.healthnet.com Out-of-Network 30% 20% $50 30% per day (Days 1-10) Subscriber Name: MIKE A. SMITH (SAMPLE) Subscriber #: R00000000 In Network Acupuncture, Chiropractic, Naturopathy Medicine Chiropractic (Medicare Covered) Massage Therapy Out-of-Network $15 $15 $25 $15 $50 $25 Medical Plan: SAGE Group ID: MO210A RX Claim Processor: Caremark Rx BIN #: 004336 Rx PCN: ADV Rx Group: RX6270 CMS Contract: H5520 007 Issuer: 80840 BACK OF CARD Treatment Review Send Medical Claims to: Health Net Medicare Advantage P.O. BOX 14130 Lexington, KY 40512 Send Pharmacy Claims to: Health Net Pharmacy Claims Dept. 13221 SW 68th Parkway Tigard, OR 97223 If you have questions regarding prior authorization requirements, please refer to your benefits information or contact Health Net’s Member Services at the number on this card. Providers: If you have any questions regarding this Medicare Advantage PPO, please contact Health Net Member Services at 1-888-445-8913 (prompt #3), Monday-Friday, 8 a.m.-5 p.m., except holidays or go to www.healthnet.com Pharmacists: For billing assistance, call the Pharmacy help line at 1-888-865-6567 Member Services: 1-888-445-8913 (prompt #2), TTY: 1-800-929-9955 8am-8pm, seven days a week. www.healthnet.com _________________________________________________ Complementary Care Benefits call ASH: 1-800-678-9133 Decision Power - to access a Health Coach (24 hours a day, 7 days a week) call: 1-800-893-5597 (TTY: 1-800-276-3821) If an emergency arises: Call 911 or go to the nearest hospital or emergency care facility. If you are unsure of the seriousness of your condition, you may call your physician for assistance. Material ID# H5520-07-0043 CMS Approval (10/07) page 3